Quantitative analyst and writer, mostly. Primus inter pares Santa Fe fan, bookworm, statistician, SAS programmer, teacher, perpetual student, musician, songwriter, photographer, 2 guard (Mr. No-Hops, a.k.a. "old school"), skier, loyal husband, father, grandfather, friend.
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Public Optional

To use an aviation analogy, we have turned from the downwind vector and are now in mid-approach "base leg" on this policy reform flight prior to turning 90 degrees into the turbulent fall 2009 headwinds of final approach and (crash?) landing of "health care reform" legislation. I will add a few more observations, and recap central points and issues I've addressed in my prior three posts before moving on to another topic (drought and water policy).

"PUBLIC OPTIONAL"

I am really sick of hearing about the "public option" wrangle 24/7 in the media these days. I am increasingly skeptical of its inclusion of any final legislation that may or may not reach the President's desk, and likewise skeptical that it would comprise much of an improvement even should it pass the Congress (and, it looks increasingly to me like a slickly orchestrated "misdirection" strategy). Without a "public option" (our having taken Single Payer off the table a priori), it is difficult to see what "health care reform" would truly amount to. But, then, "public option" as currently proffered (e.g., H.R. 3200) merely looks like -- as I've said before -- [1] corporate welfare ("Play or Pay" forcing everyone to buy health insurance policies, under threat of tax penalty), and [2] outright "welfare" (means-tested government subsidy for health insurance "affordability").

The sarcastic title of this post simply alludes to the very real political fact that, to the extent that the priorities of key legislators align with true needs of the aggregate public (e.g., universal access, better clinical quality, and restraint on cost), they will work for such things, but, the overriding, never-ending imperative of most lawmakers seems to be simply that of re-election. And, for the Legislative Branch (in particular the House**), there's only one viable source of effective campaign funding -- special interest money. This is beyond debatable, and is not exactly news. You might be able to mount and sustain a viable Presidential campaign on broad-support grassroots small-increment donation money -- as Obama obviously did -- but this is simply not the case for Senators and Representatives. It has been recently reported that there are today six health care industry lobbyists in place for every member of Congress. The money is flowing generously, and the backroom special interest pleading is in high gear.

[**] It has long been noted that roughly 80% of a Representative's time is spent on campaign fundraising, given the short 2-year re-election cycle. In the House, staff do nearly all of the actual legislative detail work, with the elected official mostly just stopping in for "drive-by" votes.

So, your interests as a citizen are "optional." A couple of headlines today:

This one is blanketing the TV channels of late. AHIP (American's Health Insurance Plans) is the lobbying organization for the private health insurance industry. From their March 2009 "Board of Directors’ Statement on Setting a Goal to Achieve a More Affordable and Effective Health Care System" -

Health care reform has eluded our nation for nearly a century. But today, a broad consensus is emerging that comprehensive reform of the system – that covers all Americans and provides safer and more effective care – is possible if the growth in health care costs can be brought under control. Health care costs are rising at an unsustainable rate and adding a burden on families and small businesses, and hampering our competitiveness as a nation...

Some reform advocates have long argued that we can indeed [1] extend health care coverage to all citizens, with [2] significantly increased quality of care, while at the same time [3] significantly reducing the national (and individual) cost. A trifecta "Win-Win-Win."

Note the soothing v/o in the AHIP PSA above: "...If everyone's covered, we can make health care as affordable as possible (0:14)...and the words 'pre-existing condition' become a thing of the past (0:19)..."

Laudable, without a doubt (notwithstanding the red-flag weasel phrase "as affordable as possible").

Again, citing the AHIP Directors' Statement:

Health plans are doing their part by pioneering disease management and care coordination programs; promoting prevention, wellness and early intervention; and implementing innovative payment strategies that reward performance and outcomes. We are committed to working with the Administration, Congress and other stakeholders to advance strategies that promote effective, efficient, and high-value health care.

The real debate, the only one that counts, is how much money our blood-sucking insurance, pharmaceutical and for-profit health services are going to be able to siphon off from new health care legislation. The proposed plans rattling around Congress all ensure that the profits for these corporations will increase and the misery for ordinary Americans will be compounded. The corporate state, enabled by both Democrats and Republicans, is yet again cannibalizing the Treasury...

...The Democrats are collaborating with lobbyists for the insurance industry, the pharmaceutical industry and for-profit health care providers to craft the current health care reform legislation. “Corporate and industry players are inside the tent this time,” says David Merritt, project director at Newt Gingrich’s Center for Health Transformation, “so there is a vacuum on the outside.” And these lobbyists have already killed a viable public option and made sure nothing in the bills will impede their growing profits and capacity for abuse.

A commentor on Salon.com notes:

A Broken Process

As I've said before; our political system is not capable of dealing with long term complex issues. Between entrenched special interests that fight to maintain the status quo, a legislative branch beholden to those interests, a political culture that only looks as far as the next election cycle, a fundamentally broken news media, an ignorant misinformed and unengaged electorate and a host of other problems it will be miracle if US makes to the half century mark as anything other than third rate power with most of its citizens living in abject poverty trying to get buy with crumbling infrastructure and a collapsing environment.

A skeptical commentor in my local paper observes:

Trust in government must be earned. The 'government' programs called Social Security and Medicare have been headed for insolvency for years. What have our representatives done about that? Nothing. We have needed real immigration reform and a sane immigration policy for years. What have our representatives done about that? Nothing. I could go on but you get the point. Health Care insurance needs reform and it will not be reformed without some government action. That said, it is possible for the present system to be reformed by legislation and not replaced by a full government program if our representatives took some tough action. But just like Social Security, Medicare and Immigration, either nothing gets done or what is done is overkill or ineffective or both. I feel both shame for my government and fear of my government and in my estimation I have good reason...our government has done such a poor job for so long on so many big issues I don't have much belief in them at this point.

An even more skeptical commentor writes to my other local paper:

It is important for all of us to realize that the health care legislation currently being hotly debated is not about insuring the uninsured, reducing health care costs, etc.

This legislation is all about power -- greatly expanded power for the Obama administration, for Speaker of the House Nancy Pelosi and for Senate Majority Leader Harry Reid.

The federal government and the unions already effectively control the American automobile industry. The government has recently gained great power over the financial institutions of the United States.

Renewable energy regulations give the government a lot of power over utilities. If the cap-and-trade legislation passes the Senate, the government will totally control the production of energy in this country.

If the proposed health care legislation passes, the federal government will control one-sixth of the U.S. economy. President Obama's appointed czars and other unelected bureaucrats will control the health care system in the United States, maybe not in the next year, but certainly within the next five years.

Make no mistake, this health care legislation is all about power.

That is why President Obama, even in the face of stiff opposition from some of his own Democrats, refuses to give up his demand for a government-run health care system to compete with the private sector.

It is precisely this frequently heated divergence of characterization that comprises the core of the health care policy reform issue soon to resolve itself one way or another, for better or worse.

"OK, so, what exactly is AHIP Job?"

From the March 2009 AHIP Directors' Report:

What Our Community Brings to the Table

Health plans offer strategies and tools to consistently improve quality and drive down the cost of care delivered to patients across all care settings:

Tools to Coordinate Care Across a Variety of Settings for Specific Patient Populations: Health plans have a wealth of administrative and clinical information which can be integrated to help clinicians have a comprehensive view of a patient’s clinical history. For instance, plans may evaluate this [sic] data to identify preventable medical errors, providing clinicians with this information to address gaps in care and help make efficient, informed patient-care decisions.

Incentives for an Interconnected Electronic Health Care System: A fully integrated, electronic health information exchange is essential to ensuring that high-value health care is delivered to the right patient, at the right time, and in the right setting.

Clinical Decision-Making Based on Best Evidence: Health plans encourage clinical practices that rely on best data and best evidence. A strong base of evidence can help evaluate whether the costs of services, devices, and drugs are commensurate with the value of care delivered.

Innovative Payment Models That Drive Real Delivery System Change: Health plans have experience with and are committed to innovative payment models that reward improved clinical outcomes and overall health status, and optimize the patient experience, such as an enhanced medical home, paying for episodes of illness, and shared risk models that promote comprehensive care management.

Benefit Design: Plans can implement benefit design strategies to encourage consumers to choose the safest, highest quality and most cost-effective drugs, devices, and procedures. These strategies include offering lower cost sharing for those procedures and technologies that are proven to be the safest, higher in value and lowest in cost.

Administrative Efficiencies: Health plans, in concert with providers and consumers, can drive down administrative costs and by doing so, improve efficiency and care delivery.

Mostly all high-mindedly Mom & Apple Pie laudable, no doubt. The foregoing, however, do beg a few questions. First, if the AHIP membership is equipped with and savvy with "strategies and tools to consistently improve quality and drive down the cost of care," then why the evolved crisis nearly everyone agrees is extant? Why the pressing, politically front-burner imperative for comprehensive reform? Why do we see chronically suboptimal, uneven outcomes quality, and cost escalation running three times the rate of inflation -- in particular when concomitant with the AHIP membership's enviable, ever-increasing profits?

Feeling the policy reform heat, are we? [1] "Health plans have a wealth of administrative and clinical information which can be integrated to help clinicians have a comprehensive view of a patient’s clinical history." Really? I would take issue with this with respect to private, and most notably, employment-based coverage. "Plan-hopping" has become a commonplace, as bottom-line anxious employers increasingly shop the most affordable benefits plan du jour. As I noted in a prior post, during my last two-year job tenure, my employer switched plans THREE times. I had no say in the matter, and was not consulted in advance. Each time, my personal "administrative and clinical information" became the private HIPAA-firewalled "business intelligence data" of the new vendor. Seamless ongoing longitudinal "continuity" of my "patient history" may have a nice ring, but it is not the predominant reality -- except, I should note, for those covered under Medicare or the VA, i.e', the public entitlement de facto "single payer" programs.

[1.b] "...plans may evaluate this [sic] data to identify preventable medical errors, providing clinicians with this information to address gaps in care and help make efficient, informed patient-care decisions." Well, that is precisely the type of analytic data-mining work I did during my two tenures with the Medicare QIO. It is also the type of extensive outcomes research performed by the CMS Agency for Healthcare Research and Quality (AHRQ). A salient -- no, critical -- difference is that entitlement beneficiaries are not put at risk of coverage exclusion/"rescission" that is increasingly common within the for-profit actuarial insurance model.

[2] "A fully integrated, electronic health information exchange is essential to ensuring that high-value health care is delivered to the right patient, at the right time, and in the right setting." Yes, of course. Again, see my foregoing comments in response to [1]. These things go the acronym "RHIO" or "RHIE" ("Regional Health Information Organization/Exchange"). The Utah Health Information Network (UHIN) stands as a fairly mature example here. During my last QIO tenure, I sat on the Steering Committee for a southern Nevada RHIO startup attempt. I recall the fractiousness of the proceedings, given the disparate interests of the various for-profit and non-profit interests. We still don't have one in Nevada. I applaud these efforts, but they remain fraught with technical and policy difficulties [a], difficulties that would be significantly abated under a universal coverage "social insurance" paradigm (be it a "Single Payer" model or one more akin to a "Swiss Model").

[a] The private sector "EMR" (Electronic Medical Records) industry -- regarding which I am thoroughly evangelistic -- has been in high gear for a number of years and has matured greatly, but it has nothing to do directly with the health insurance industry, except to the enervating extent that the latter significantly complicates the work of the former. An integrated EMR is one wherein the front office (demographic & scheduling), mid office (the clinical/patient encounter and historical record), and back office (billing and admin) functions are synch'd (with automated CPT/ICD-9 encounter coding linked with the front and back office functions). The focus, though, ultimately remains that of reimbursement, i.e., the back office imperative of billing -- having to deal with the hundreds of 3rd party payers, each with their own proprietary submissions forms, policies, and procedures. This adds nothing substantive to improved actual health careeffectiveness. Single Payer would simplify this aspect of health information technology immeasurably, enabling software developers and their end-users to focus more on leveraging the EMRs for better care.

[3] "A strong base of evidence can help evaluate whether the costs of services, devices, and drugs are commensurate with the value of care delivered." Again, no argument with that ideal. However, again, it begs the question of efficiency and effectiveness, when health care data constitute in large measure the proprietary "business intelligence" of competing for-profit actuarial model enterprises. By contrast, the research initiatives of public entities such as AHRQ (a) suffer from no such potential profit-model conflicts-of-interest, and (b) are already focused on patient populations with the higher levels of utilization experience (increasingly so as the population ages)

[4] "...innovative payment models that reward improved clinical outcomes and overall health status..." It's called "P4P" (Pay for Performance), already long a front-burner priority within CMS. Nothing exactly "innovative" about it -- it's called "evidence-based medicine," i.e., "science," which results in "clinical practice guidelines" (which, it should be noted in fairness, is derisively referred to by numerous skeptical docs as "cookie-cutter medicine"). I find it the height of hypocrisy that this is touted as a virtue by the likes of AHIP while it is also attacked by reform opponents as looming, ominous "death panels" and "federal health/lifestyle police" if undertaken by the public sector.

[5 & 6], OK, what, precisely, have you been waiting for? AHIP claims that their membership "can" do these things. The private sector for-profit evidence to date seems to infer the opposite.

___

MENDACITY OF THE DAY

"And you know what public option is? It leads to single-payer, completely government-run health care system and no choice. And we want to preserve choice for our people."

- Senator Charles Grassley (R-IA), Des Moines Register, 09/25/09___

Main Entry: op·tionPronunciation: Ëˆäp-shÉ™nFunction: nounEtymology: French, from Latin option-, optio free choice; akin to Latinoptare to chooseDate: 15931: an act of choosing2a: the power or right to choose: freedom of choice

First of all, we have had Medicare in place for 44 years now. And, guess what? This government entitlement beneficiary cohort also can and does avail itself ofprivate sector "Medi-Gap" insurance coverage. And, guess what? The Evil Government-run agency Medicare itself touts these policies on its website:

Medigap (Supplemental Insurance) Policies

A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will pay both their shares of covered health care costs...

More to come, stay tuned...

BTW, I am fully updating this post at bgladd.blogspot.com. The Open Salon editor is simply too feeble for lengthier posts.___

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Comments

I wish I could say otherwise, but this post seems as accurate (both as analysis and as prediction) as anything I've read recently on the topic.

when "the priorities of key legislators align with true needs of the aggregate public (e.g., universal access, better clinical quality, and restraint on cost), they will work for such things, but, the overriding, never-ending imperative of most lawmakers seems to be simply that of re-election"

That's the crux of the matter right there, or one of the points of gravity at least. When I started hearing news talking heads and analysts last week bringing up how lawmakers are rattled because the whole debate may affect their chances for re-election, I realized this thing is largely over except for the shouting.

My heart breaks given the promise of a hopeful nation for all citizens. I foresee all the lies and rhetoric coming to fruition once the private insurers have the strangle hold on insurance coverage (Note: I did NOT say health care). I think we are moving to Europe not long after it happens. I can not be with fourth rate care under my current union plan and I can not afford another plan (not that third rate is much better). As with most parents who have a kid with permanent disabilities, I am obligated to live for ever. It is the only way to be sure he gets true advocacy. Systems exist for their own perpetuation, not for the mission statement or the higher values espoused. Blood is definitely thicker than rules and regs. Luckily, some countries (unlike the US and Canada) will actually accept him and he can keep his Social Security check coming. It will be difficult to leave everyone else we love, but where will be the choice?